INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 10, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Spanish American Civic Association for Equality, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on a review of fire drills from January 2021 thru December 2021 the facility failed to conduct a sleeping fire drill at least every six months. The last sleeping fire drill was completed April 2021.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from the March 30, 2021 licensing inspection.
|
Plan of Correction
Director met with facility manager and explained the overnight fire drill. Director established a schedule for manager. Facility/Operations manager will complete at least one overnight drill every six months and give proof of these drill monthly to director for verification. |
709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
|
Observations
Based on a review of client medical records, the facility failed to ensure that missed medication was documented in the medical records in five applicable client records reviewed.
The findings were discussed with facility staff during the licensing process.
This is a repeat citation from the March 30, 2021 inspection.
|
Plan of Correction
Director retrained staff on documenting medication and established new format. Facility manager will audit medication book weekly for the next 3 months, then biweekly going forward. Proof of audits will be supplied to director. Director will do random audits going forward at least monthly. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based on a review of seven client records, the facility failed to document a physical examination of the client in three client records reviewed.
Client #2 was admitted on December 2, 2021 and was still active at the time of the inspection. There was no documentation of a physical examination in the client record at the time of the inspection.
Client #4 was admitted on November 11, 2021 and was still active at the time of the inspection. There was no documentation of a physical examination in the client record at the time of the inspection.
Client #6 was admitted on May 17, 2021 and discharge on October 16, 2021. There was no documentation of a physical examination in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the March 30, 2021 licensing inspection.
|
Plan of Correction
Director met with facility manager and advised that all referrals must contain an H&P. Facility manager will request with from all referral prior to admission will all new referrals going forward. Director will do random audits within in a week of new admissions to ensure compliance |
709.53(a)(12) LICENSURE Work as treatment
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
|
Observations
Based on a review of seven client records, the facility failed to ensure that all work done by the client at the project is an integral part of the treatment and rehabilitation plan in three of seven client records reviewed.
Client #1 was admitted on December 17, 2021 and was still active at the time of the inspection. There was no documentation in the client ' s treatment plan that all work done by the client at the project is an integral part of the treatment and rehabilitation plan
Client #3 was admitted on January 13, 2021 and was still active at the time of the inspection. There was no documentation in the client ' s treatment plan that all work done by the client at the project is an integral part of the treatment and rehabilitation plan
Client #7 was admitted on September 9. 2021 and was discharged on November 7th, 2021. There was no documentation in the client ' s treatment plan that all work done by the client at the project is an integral part of the treatment and rehabilitation plan
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Director met with facility staff to retrain on the process and purpose of work done on premises. Facility manger will ensure compliance during weekly audits for t he next 6 months then biweekly going forward. |